Perfecting the Hand-Off – to Better Coordinate Care

Our vision is to treat everyone as we want our own loved ones treated. Most of us have had loved ones with some chronic disease where our loved one was caught between providers of care and we had to try to bridge the gap. I often get calls from family members asking me to help resolve differences of opinion between providers. I have told the story of a woman who was admitted to the medical intensive care unit at GBMC with diabetic ketoacidosis because her insulin plan was wrong. Our physicians and nurses got her back on her feet and discharged her to the care of her doctor. Unfortunately, her doctor put her back on her previous plan and she ended up back in the Emergency Department. It seems that her doctor did not get the message about her new plan at the time of her discharge. A clear lack of coordination.

How do we fix this? 

Well, the improvement has to start with someone being willing to coordinate the care. This is why the GBMC HealthCare system has embraced the concept of the patient-centered medical home (PCMH) because the physician-led team knows that it is accountable to provide the coordination 24 hours a day, 365 days of the year, and actually has the capability to do that! Also, the other members of the healthcare system must work with the primary care teams at the time of handoff, like when a hospitalist is discharging a patient from GBMC back to the primary care physician.

The Head of the GBMC hospitalist group, Rekha Motagi, MD, and her team have been working tirelessly to improve the handoff back to the primary care doctor. You can imagine that communicating to literally hundreds of different doctors and offices can be quite a challenge. Rekha and her colleagues have been redesigning their communication process and measuring its performance as a measure on their Lean Daily Management board. Every day on our management rounds, Rekha or one of her hospitalist colleagues and members of our two internal medicine resident teams, report on the percentage of the previous day’s discharges where they have had a high quality communication with the primary care physician or his or her office staff. As a result of their work, they rarely miss a handoff with a GBMA PCMH practice and we are seeing improvement with our non-GBMA practice colleagues as well.

I’ve asked Dr. Motagi to explain the obstacles that have been identified and the improvements that have been made in the transition of care since the team started testing changes:

Rekha Motagi, MD

Dr. Motagi explains: 

The hospitalist group has always made it a priority to communicate with a patient's primary care physician to provide verbal hand-off when patients are discharged from the hospital. This is a very important aspect of the transition of care. Reviewing a patient’s hospital course, medication changes, test results and pending tests during this hand-off is also an important patient safety measure.

Previously, we were not sure how consistently this hand-off communication was occurring in our large group and the reasons we were not always successful. But since we started the lean daily management process, where one of our metrics is for each physician to note if they have been able to reach the PCP for discharge hand-off, we have identified several areas for improvement.  

About 90% of the time, our doctors have made an attempt to reach the patient’s PCP; but we've only connected with them from 50-70% of the time due to various reasons including:

• Offices were closed or the front office did not want to interrupt the PCP. In these instances, we left a message but were not sure if the PCP received it (This becomes much more challenging on weekends/holidays.)
• We have been put on hold for 10 minutes or more; in many instances, our doctors have had to hang up because they needed to respond to other calls
• The PCP was on vacation, so there was no way to ensure they received the message
• There is no attempt made to call when there is no PCP or if the patient is going to be transferred to a facility and no provider in the facility has been identified

Since we started Lean Daily Management, the physicians relations office (Mary Ely, Ann Veltre and Bonnie Longerbeam) has been working to reach out to several physician groups to obtain their feedback on the best ways to accomplish a successful transition of care. What we've found is that there are some PCPs who are very involved in their patient's hospital stay. Some are interested in receiving the call from the hospitalist, but only call back if they have questions. From this outreach, we've been able to make improvements and design a more effective system for coordinating the transition of care, including:

• Obtaining back-office telephone numbers for PCPs (and in some cases cell phone numbers) which provides us with faster access to some of the PCPs
• Updating incorrect physician office numbers in our database 
• Identifying physician offices that have care co-coordinators (RNs) who will take the patient’s information, relay it to the PCP and contact patients to arrange follow-up

We are now working with all primary care providers to further standardize this process. Our group is also committed to making sure the written communication (discharge summary) is completed within 48 hours of a patient being discharged. Currently, we are over 95% compliant with this effort and we are working to get this rate to 100% so that the information is there for the PCP to use in follow-up.

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I want to thank Dr. Motagi, our hospitalists, our internal medicine residents, the physician relations group and our PCPs for their commitment to creating a more reliable system for patient hand off. Continuous improvement requires a focus on who it is that we are serving, system design, measurement, teamwork, and empowerment. Lean daily management appears to be helping us speed up the implementation of all of the above!